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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336427578
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:41:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2023 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230210115209
FACILITY NAME:FOOTHILL LAKE HOMEFACILITY NUMBER:
336427578
ADMINISTRATOR:ANGELITO V. MENDOZAFACILITY TYPE:
740
ADDRESS:24746 MORNING MIST DRIVETELEPHONE:
(951) 208-1722
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92557
CAPACITY:6CENSUS: 3DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Evelyn Manuel, CaregiverTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff yells at resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an investigation of the above allegation. LPA met with caregiver Evelyn Manuel. Administrator Julita Mendoza arrived while conducting the visit.

The allegation that staff yell at residents has been investigated. Interviews revealed staff yell at residents when they become frustrated while assisting them. Staff One (S1) understands that yelling is an inappropriate method of communicating with the residents; whereas, they will never yell again when communicating with residents. Therefore this allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20230210115209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FOOTHILL LAKE HOME
FACILITY NUMBER: 336427578
VISIT DATE: 02/16/2023
NARRATIVE
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An exit interview was conducted where a copy of this report was discussed with and provided along with a copy of the LIC9099-D, and Appeal Rights.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20230210115209
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: FOOTHILL LAKE HOME
FACILITY NUMBER: 336427578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not being met as evidenced by:
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Licensee agrees to conduct in-service training with all staff on the cited regulation and provide proof of such to LPA by POC date.
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Based on LPA interview with staff and residents, LPA found that the Licensee did not adhere to the regulation. S1 admitted to yelling at residents when they become frustrated. This presents a potential personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3